THEINTERROGATINGGENDERGAP DEATHSOVERDOSEIN BULLETIN VOLUME 19 EDITION 3 BARRIERSREMOVINGNALOXONEBYHEPAUSTRALIA:C-FREE2030?THETOACCESS HORSBURGHKIRSTEN Director of Operations at Scottish Drugs Forum THE
On behalf of Penington Institute, I want to extend our thanks to everyone who has participated in IOAD this year. Penington Institute serves as the primary convenor of IOAD, but it is not ours alone. Thousands come together every year to remember without stigma the lives lost to overdose and demand action from those in power. IOAD has always belonged to them.
It feels fitting that for this issue we are shining a light on a topic that is frequently marginalised even within broader discussions of overdose. We have known for years that accidental drug-induced deaths occur far more often in men than in women, but few seem concerned to ask why. Whether this silence is due to the emotionally charged subject matter or the bewildering complexity of the data, it is a question that all too often gets relegated to the ‘too hard’ basket.
John Ryan CEO Penington Institute
The August–September period has always been a busy time for Penington Institute, and 2022 is no exception. As the coordinator of International Overdose Awareness Day (IOAD), much of our work throughout the year is building toward August 31st. Along with Australia’s Annual Overdose Report 2022, this year we have also created for the first time a Global Overdose Snapshot
Penington Institute connects lived experience and research to improve the management of drugs through community engagement and knowledge sharing. A not-for-profit organisation, our focus is supporting cost-effective approaches that maximise community health and safety in relation to drugs including pharmaceuticals and alcohol.
Copyright © 2022. All rights reserved. All written material in this publication may be reproduced with the following citation: “Reprinted from vol. 19, ed. 3 of The Bulletin, published by Penington Institute, with credit to the author(s).” www.penington.org.au
This issue also includes a Q&A with Kirsten Horsburgh, Director of Operations at Scottish Drugs Forum and an indomitable force in the world of harm reduction. Next is an overview of the rollout of Australia’s national Take Home Naloxone program, and Katie Horneshaw provides an update on Australia’s commitment to eliminate hepatitis C by 2030.
A FROMMESSAGETHECEO
DISCLAIMER. The Bulletin is published by Penington Institute and funded by the Australian Government. The views expressed in this publication are not necessarily those of the Australian Government or Penington Institute.
For the second year running, US President Joe Biden issued a proclamation making Overdose Awareness Day an official US national day. Remember that IOAD started as a small community event in Melbourne: that it has been embraced by so many and reached the attention of the world’s most powerful leaders is a good indicator of the enormity of the crisis. It is also a testament to the size of our global community and its tenacity in bringing overdose out of the shadows.
Penington Institute takes no responsibility for loss or damage that may result from any actions taken based on materials within the Bulletin and does not indemnify readers against any damage incurred.
Jarrod McMaugh, manager for the Victorian branch of the Pharmaceutical Society of Australia, confirms that the program is currently being rolled out by the Victorian Government.
Implementation of the national Take Home Naloxone program began on the first of July this year. Between now and November, when the rollout is due to be completed, naloxone will be made available without a prescription and free of charge through participating pharmacies and service providers across Australia.
By Shivani Prabhu
The national program is a victory several years and thousands of workhours in the making. In 2018 Penington Institute presented Australia’s first detailed outline for a national naloxone program. Following the roadmap set out in that document, the pilot THN program was launched in 2019, making naloxone available free over the counter in Western Australia, South Australia and New South Wales.
On the heels of the pilot program, the federal government began a phased national rollout in July 2022. Phase one involves making naloxone available through pharmacies and approved medical practitioners – these are the program’s ‘approved providers’. Phase two will target ‘authorised alternative providers,’ a category that includes NSPs, drug treatment providers, and homelessness outreach services, among others. The end goal is to achieve complete national coverage by the first of November.
THE IMPLEMENTATIONNATIONWIDE OF THE TAKE HOME NALOXONE PROGRAM
The federal government has launched a program aimed at increasing naloxone access across Australia by the end of 2022. Naloxone, the life-saving drug that reverses opioid overdose by blocking the brain’s opioid receptors, was previously only available free of charge in three states under the pilot Take Home Naloxone (THN) program. The success of that trial prompted the federal government to expand the program to all Australian states and territories.
The trial was widely hailed as a success – an evaluation undertaken by the University of Queensland found that it was saving an average of three lives per day – and it laid the groundwork for national scale-up.
TOTHEREMOVINGBARRIERSACCESS
“While we have had some level of take-home naloxone provision going on outside of the trial, it’s been at a relatively small scale,” Robert explains, “so we’re seeing that
Frontline workers and policy officials are encouraged by the trial and eager for national rollout to occur, but there is some concern about stock shortages.
A source from the Western Australian Mental Health Commission, however, said “there’s some extra stock of naloxone being diverted and redirected to Australia, so we don’t think it will be an issue at this time. There might be some pressure, but it should be resolved in the next month.”
“
“There’s a worldwide shortage of naloxone products,” Robert says, “and ever since COVID-19 there have been supply issues. So there are logistical things that will be overcome with time, but [which] might present some challenges along the way.”
Rebecca Biglane Coordinator of Health Promotion and AOD at WAAC WAAC LIFE - SAVING
WE’VE HAD CLIENTS WHO’VE BEEN ABLE TO RESPOND TO OVERDOSES AND IT’S BEEN TO BE ABLE TO IMPLEMENT IT. “ scaled up significantly in a short period of time, and we’re also trying to estimate what the demand turns out to be.”
Robert Kemp, Principal Public Health Officer at Queensland Health, says that Queensland is in negotiation with the Commonwealth regarding the details of the THN program.
“Pharmacists will provide counselling to clients who request it, whether they’re a person who injects drugs themselves or they’re someone who may witness an overdose.
The additional funding that comes with nationwide rollout
Rebecca Biglane, Coordinator of Health Promotion and AOD at Perth-based sexual health and harm reduction services provider WAAC, affirms that the THN program has been a great win for her clients.
“WAAC was on board with the pilot in 2019,” Rebecca says, “and we’ve implemented that through our NSP, distributing naloxone to clients who seem like they’re at risk of overdose or likely to witness overdose.”
“Pharmacies can now provide naloxone without prescription and with no out-of-pocket charge and NSPs will soon be able to do the same. Each state is updating their regulations to allow naloxone to be provided from community health centres and NSPs so that non-pharmacists can provide it, with additional training.”
While pharmacists are already trained in the provision of naloxone to clients, Jarrod explained that they will also provide advice on the use of naloxone products.
For the nasal spray it’s a relatively straightforward process, and for the ampoules and the Prenoxad [pre-filled syringes] – which have a particular storage device that can be a little tricky to open – the pharmacist will confirm that the client knows how to operate that correctly. If they’re ampoules, the pharmacist will also check if the client needs clean injecting equipment.”
“There’s also a lack of recognition from people who have been prescribed opioids that they’re at risk. People who are using opioids, regardless of the strength and regardless of whether they’ve been prescribed them, are still at risk of overdose and they still need access to this medicine.”
has meant organisations can step up their service delivery: WAAC is expanding their service from NSPs to outreach programs and postal services.
“ Jarrod McMaugh Pharmaceutical Society of Australia THEY’RE AT RISK.
Jarrod elaborates: “There is concern that health providers would have stigma-associated interactions, but there’s also selfstigma: some individuals don’t want to seek help because they don’t think they want to be treated or think they don’t deserve it, and that’s a real insidious misconception that we want to overcome as much as possible.
“Through education we’ve been able to advocate for peers,” Rebecca continues, “and they’ve administered naloxone and saved lives. I’ve had clients who have administered naloxone and they’ve felt really empowered to be able to respond in that situation. Giving them the tools to get someone breathing again and having the education and knowledge on how to respond properly has given them a lot more confidence and empowerment.”
Rebecca also endorses this model of supported-yetautonomous decision making and the creation of ‘safe spaces.’ “We build rapport with clients,” she says, “which allows us to raise these conversations. We acknowledge that people are going to use drugs, we just want to talk about how to do it safely so naloxone becomes part of that conversation. It’s been easy for us to implement, and clients are happy to take it on board.”
THERE’S ALSO A LACK OF RECOGNITION FROM PEOPLE WHO HAVE BEEN PRESCRIBED OPIOIDS THAT “
Some people who use opioids may have apprehension about accessing naloxone, or not recognise they need it.
15 Q&AWITHKIRSTENHORSBURGHDirectorofOperationsatScottishDrugsForum
Kirsten Horsburgh is the Director of Operations at Scottish Drugs Forum. She spoke to The Bulletin about Scotland’s high incidence of overdose, the recent HIV outbreak, and how stigma in the healthcare sector is stopping people from accessing lifesaving services. How did you end up where you are now in your position?
My understanding of SDF is that it’s fundamentally a harm reduction organisation. And you didn’t mention the words harm reduction just then. Have I got the wrong end of the stick?
I’m a mental health nurse. My first job working with people who use drugs was when I was working in a mental health ward. We had a couple of beds for people who were experiencing drug problems, so it was a bit of an unusual environment for people to come into. To me, it seemed like people who were coming in with drug and alcohol problems were treated like, “oh well, they don’t really matter as much as the rest of the residents.” I took a particular interest in working with people who use substances, and then a job became available at the local addictions team. I worked there for a few years and was team manager when the national naloxone program was introduced. We worked on that locally and then a job appeared at Scottish Drugs Forum (SDF) to work on the naloxone work nationally. That led me to SDF, where I’ve now been for 10 years. And can you just explain briefly what SDF is for the Australian audience? SDF is a non-government organisation. It’s a charity, membership-based organisation. We are a drugs policy organisation. We’re not a treatment service, but we are policy based and a large part of our work is also delivering training. We have programs of work on peer research, drug-death prevention, on sexual health and blood-borne viruses, and a whole variety of other things.
THIS NARRATIVE GETS THROWN AROUND A LOT ABOUT, OH YOU’RE EITHER HARM REDUCTION OR YOU’RE RECOVERY. AND WE DON’T SEE IT LIKE THAT. IT’S VERY MUCH SPECTRUMA “ “
No, definitely not. Our ethos is very much based in harm reduction. Over the last few years, harm reduction interventions have been criticised quite heavily by some, particularly organisations that are focused on the residential rehab angle. I think sometimes we are seen as an organisation that doesn’t support an abstinence-based approach, which is not the case. We believe that people should have the choice for anything and everything in terms of their own personal goals. But we are very much harm reduction focused, so that is always at the core of everything that we do. One of the things that’s fascinated me in the UK has been the sort of recovery paradigm and the recovery language. Are recovery and harm reduction getting closer or are they still seen as mutually exclusive? In 2008 we had a drug strategy produced that was called the Road to Recovery, and that whole strategy was about moving away from problem drug use. And whilst it didn’t explicitly talk about an abstinence-focused model, that was certainly how it was construed. A lot of organisations focused then on that push towards abstinence, which was really quite harmful. I mean, it depends on your definition of recovery. And certainly, ours is more about any positive change. For one person recovery might be the first time they start using sterile injecting
equipment every time they use; for somebody else, it might mean complete abstinence. So I think it’s down to the individual. This narrative gets thrown around a lot about, oh you’re either harm reduction or you’re recovery. And we don’t see it like that. It’s very much a spectrum.
Unfortunately, we still have a big issue with the two being seen as very separate things. In Scotland, our staffing for drug services will be a proportion of mental health nurses, as well as general nurses. But if somebody comes to your drug service and they are experiencing significant mental health issues and you refer to a specialist mental health team, often you’ll be faced with “we can’t take them because they need to get their drug use under control first.” So you’re left in this vicious cycle where somebody is experiencing mental health problems, they’re using drugs often to manage those mental health symptoms, but then they can’t access specialist mental health services.
And what about trauma-informed care and harm reduction?
A lot of the clients, particularly the ones that are injecting, have got significant mental health issues. How do you see mental health and harm reduction coming together?
SDF does a lot of training around trauma and substance use, and I guess for me, trauma-informed practice is a lot about also addressing stigma. So yes, being aware of people’s histories and taking that into account and how trauma can affect where somebody is at [is important], but [so is] thinking about the way that we provide our services. We have to ask ourselves – if you take injecting-related wounds, for instance – why is it that people would have
The majority of people that are experiencing drug problems will have often significant trauma in their life. And that’s something that we don’t capture early enough in people’s lives. People have often experienced unimaginable trauma, and then it’s perpetuated by the situation that they’re finding themselves in, in terms of poverty, deprivation, homelessness. [It’s] this sort of ambivalence where [they think] “I don’t really want to die, but I’m not that fussed about living either.”
Sometimes I worry that we over-diagnose people with a mental health condition when actually, a lot of it is situational. So I think there’s a bit of both, but certainly some severe and enduring mental health issues in amongst all of that as well.
such hideously painful wounds and carry that around rather than approaching one of our health services? It’s about stigma, because people know how they’ll be treated when they attend a service.
When I think about Scotland, unfortunately, the thing that jumps to my mind is the very high overdose rate. Why is it so Webad?have
There’s a lot of work that we need to do about how we make our services approachable. You can’t be trauma informed if you still have punitive practice and you’ve still got that angle of stigma within your organisation. And that also links to a lot of work that we’ve been doing with other organisations, like police. We recently finished a program where we supported them with a trial of naloxone carriage for police officers, and there was still a lot of stigma amongst police towards people who use drugs, which you can imagine because of the criminalisation.
very high rates of people experiencing problem drug use, especially in areas of poverty and deprivation. The number of drugs that people are using together is higher than some other places. We have lots of opiate use, heroin and methadone are the main ones. We have huge rates of benzodiazepine use. We also have a lot of alcohol use, but we also have other drugs in the mix now. Gabapentin and pregabalin are quite commonly used. Over the last couple of years, we see way more people using cocaine as well. And not just cocaine on its own, but cocaine in combination with opiates. We also have lower rates of people accessing drug treatment. We have around 60,000 people experiencing drug problems, but less than 40 per cent actually access treatment. A lot of people who die will be parents as well, so there’s that generational impact of a parent dying from a drug-related death. The average age last year of people dying was 44. People over 35 in Scotland are deemed to be older drug users, which is by no means old, but what we see is people experiencing health conditions that are way beyond their actual years. There was talk a few years ago about a consumption room in Scotland. Is that going to happen? There absolutely is still a need for safer injecting facilities, and not just in Glasgow where the proposal was made.
Proactive testing and treatment was key. There were real efforts focused on testing and they commissioned a report looking at the needs of people who were injecting drugs in public places, because that was where it was identified as one of the main issues.
Glasgow has been described as having the most compelling case in Europe for one because we had an HIV outbreak as well. That proposal is now with the new Lord Advocate and they’re reviewing that through the Crown Office to see if there’s a way that they can operate the facility within the current legislative framework. And what about the HIV outbreak, how has that progressed?
Cocaine injecting was seen as a key driver as well – the injecting frequency was a lot higher and in turn resulted in more people sharing equipment. It was almost like HIV had been seen as a thing of the past. People were more familiar with hepatitis and that was probably more in people’s discussions and [a focus] for services as well. I think HIV had sort of fallen off the radar for services.
Finally, there was recognition from the Scottish government that, in the words of the First Minister, they had taken their eye off the ball in terms of drug deaths. So they introduced, for the first time, a specific ministerial position of Drugs Policy Minister. Previously we’d always had a Minister for Public Health and Sport, who also had drugs in amongst all that, which was really unhelpful. To have a minister dedicated to drugs policy is, in our minds, really positive. The frustration that we have is that we are still talking about piloting things that are evidence based. Like, come on, in an emergency you don’t pilot things, you just get on and deliver them, especially when they’ve proven to be effective in other countries. Things like drug consumption rooms, for instance, or heroin-assisted treatment. All the things that we should just be getting on with delivering are slow.
That’s interesting. Is there something I should have asked you or is there something that you wanted to get across particularly? There’s some been some dramatic changes [in drug policy] over the last while. Organisations had been really applying pressure about the government’s lack of response on the drugs crisis. And then something like COVID comes along and you see what is actually applied when a public health emergency is taken seriously.
It was 2015 when the cases started to emerge. Generally, in Glasgow, there would be around 10 new cases of HIV every year. And there were over 40 in that year. That’s escalated and it’s now well over 100. The rate of increase has slowed, but it’s still definitely there, and the reason it’s slowed is because of the interventions that were put into place.
SO YOU’RE LEFT IN VICIOUSTHISCYCLE WHERE SOMEBODY IS EXPERIENCING MENTAL HEALTH PROBLEMS, THEY’RE USING DRUGS OFTEN TO MANAGE THOSE MENTAL HEALTH SYMPTOMS, BUT THEN THEY CAN’T GET A MENTAL HEALTH SERVICE. “ “
AUSTRALIA: HEP C-FREE BY 2030?
The Australian Government was quick to commit to the ambitious target of complete elimination of hepatitis C by 2030, but the achievement of that goal will require a health sector-wide approach to extend diagnosis and treatment services to high-risk communities, such as Aboriginal and Torres Strait Islanders, people in prison, and people with insecure housing.
“It’streatment.always at the back of your mind,” admits Sarah, 34, from Melbourne, who has lived experience of injecting drug use, “but when you think about facing judgemental healthcare workers, having to hide it from employers, or your family thinking less of you… sometimes it’s just easier not to know.”
By Katie Horneshaw
Aside from the logistical challenges of reaching people in vulnerable communities, the stigma associated with the diagnosis can render at-risk people reluctant to engage with
Hepatitis C is primarily spread through the sharing of injecting equipment, tattoo needles, and razors. In Australia approximately 232,000 people are still living with the illness, many of whom inject drugs. Professor Jason Grebely, who leads the research team for the national hepatitis C point-of-care testing program at the Kirby Institute in New South Wales, believes Australia is capable of bringing this number to zero by 2030.
In 2016 Australia celebrated a huge health victory with the arrival of direct-acting antiviral drugs (DAAs) for the treatment of hepatitis C. Unlike previous therapies, which were less reliable and produced a number of distressing side effects, DAAs are well tolerated and provide a cure in 95 per cent of recipients.
With highly effective new treatments available since 2016, Australia has committed to eliminate hepatitis C by 2030. Katie Horneshaw explains that outreach to vulnerable populations will need to be ramped up if we are to hit that target.
“Among people who inject drugs, treatment uptake is currently at around 70 per cent, and rates of infection have dropped to around 16 per cent.” In 2016 alone, 30,000 people were treated with DAAs. Jason believes a potential solution to the issue of reaching high-risk people lies in the new point-of-care testing program, which is designed to allow for one-stop treatment and testing, significantly reducing the travel and time burden involved in getting diagnosed and initiated into treatment.
Although Marc had injected drugs for many years, he hadn’t noticed any symptoms and had assumed he was in the clear. “I’m actually glad I didn’t find out till recently because it meant I was instantly treated with the new medication. I went from freaking out that I had what I thought was a lifethreatening illness to finding out I was about to be cured of it, all in the same GP visit!” But there are still major obstacles that must be negotiated if Australia is to meet its target. The rate of treatment uptake has been steadily dropping, with only 6,500 people inducted onto the antiviral medications in 2021.
“Our co-located with our needle and
fixed-site clinics are
“We won’t see the rates of treatment we’re hoping for until we address the issue of stigma. Many people in vulnerable populations avoid health services altogether because they don’t want to be pigeon-holed as an injecting drug user. Once that is on your file you will be asked about it every time you go to the doctor.”
Peta Gava, Peer Health Clinic & Outreach Worker at Peer Based Harm Reduction WA, stresses the importance of adapting to the needs of vulnerable communities: “In WA geographic distances and travel times to centralised services are a significant barrier. At PBHRWA we employ peer case management workers and peer educators to engage effectively with the most vulnerable populations.” (A peer is a person with lived experience.)
AMONG PEOPLE WHO INJECT DRUGS, TREATMENT UPTAKE IS CURRENTLY AT AROUND 70 PER CENT, AND RATES OF INFECTION HAVE DROPPED TO AROUND 16 PER CENT.” “ “
Peta of PBHRWA has been on the receiving end of stigmatising attitudes from healthcare professionals.
“I couldn’t believe how easy it was” says Marc (not his real name), 50, who was shocked to discover he had hepatitis C after his GP encouraged him to take a test last year.
Penni Moore, NSP Peer Educator at Hepatitis SA, confirms the problem is widespread: “A lot of people from these types of backgrounds have zero trust in the health sector — they’ve had negative experiences in the past where they’ve felt judged or have been denied health care based on their drug use status — and when you combine that with the lack of urgency because most people with hep C don’t feel sick and are busy just trying to get by, the chances of them turning up for diagnosis are very low.”
This is reflected in data from the Annual NeedleTorresAboriginalSyringeandProgramNationalReport,whichshowstheproportionofpeopleofandStraitIslanderdescentwhohavehepatitisChasincreasedfrom18percentoftotalAustraliancasesin2017to25percentin2021;overthesame period the percentage reporting incarceration in the 12 months prior to the survey increased from 11 per cent of all respondents to 13 per cent.
Jason explains: “The decline is happening because the populations that remain to be treated are those with multiple categories of vulnerability, and they are harder to reach.”
Margaret Randle of Hepatitis South Australia seconds the need to increase diagnostic and treatment uptake in vulnerable communities, which include people experiencing homelessness and people who continue to inject drugs. “But it’s not as simple as increasing access points,” she cautions.
To reach the people who are not currently accessing testing and treatment, we need to go where they are, not expect them to make an appointment and come to us.” Point-of-care testing “is a really exciting development,” says Jason, “because it provides an opportunity for people to receive on-the-spot diagnosis and treatment when they attend needle and syringe access points, opioid substitution therapy (such as methadone treatment), or at their alcohol and drug counselling service.” This means patients can be offered both test and treatment when they make contact with their usual services.
syringe exchanges and can provide testing and treatment in house, without the need to refer people to other agencies.
Despite this, Jason agrees that it will be impossible to reach vulnerable communities without new initiatives to address stigma and distrust in the health sector, as well as increase access to injecting equipment. He joins the many voices calling for comprehensive anti-stigma training in healthcare, anonymous point-of-care testing and treatment, and most importantly, the adoption of treatment methods that can be provided through peer networks, bypassing the need for clinic visits.
All told, Jason believes that we’re on the right track.
Sarah asserts that it’s not always easy to avoid transmission risks: “We’re lucky to have access to needles in Australia, but it can be harder than you’d think to get your hands on them.
“In smaller communities, everyone knows everyone. I wouldn’t want to risk going into the local community hub and asking for needles to inject drugs with.”
Kate believes a national strategy is needed “to commit to addressing stigma more explicitly, through the implementation of initiatives to reduce discrimination in health care settings and increase patient comfort levels with treatment access points.”
“ “
WE NEED TO HAVE TESTING AVAILABLE THAT DOESN’T REQUIRE PEOPLE TO ATTEND A MEDICAL SERVICE AND THAT CAN BE ANONYMOUSLYDONE
PBHRWA has responded to this need through a hep C peer education project. “The people who’ve accessed care through this initiative have consistently told us that they would not have spoken to a GP about hep C because of concerns about stigma and discrimination and that talking to a peer educator is the only way they would have heard the Professorinformation.”KateSeear of La Trobe University in Victoria echoes Peta’s views on the provision of peer-based care: “We need to have testing available that doesn’t require people to attend a medical service and that can be done anonymously,” she advises. “One option would be to train peer workers (people with lived experience of injecting drug use and/ or hep C) to provide the treatment at needle and syringe access points.”
“I know plenty of people who want to be tested and treated, but they’ve got higher priorities,” explains Sarah. “If you want to stop transmission and get everyone onto these hep C drugs, you’ve got to make it convenient enough that it’s not going to get in the way of their lives.”
If I score at midnight, there’s nowhere within hours of me to get clean fits. If it’s during the day, I can go to the local pharmacy, but they charge $6 for 4 needles, which is a lot of money when you’re only just getting by. And I have to deal with the salespeople giving me the stink eye.
She underscores the value of people with experience of stigma being able to access diagnostic and treatment services through peer networks: “We can invest trust in the healthcare experience when it comes from someone with parallel life experience to us, who has lived with hep C and experienced treatment for themselves.”
A final hurdle to achieving the 2030 goal is the presence of continued transmission. “In communities where transmission is particularly high,” explains Jason, “we are seeing people cured and reinfected two or three times.”
“Australia has a very progressive approach, and the funding is there to get this thing done. Unlike many other countries, we have GPs and nurse practitioners prescribing the DAA medicines, and there is a spirit of cooperation in the sector that’s great to see.”
INTERROGATING THE GENDER GAP IN OVERDOSE DEATHS
We examine alleged causes of the higher overdose death toll among men – and explain why it may mask a more complex story about gender and drugs.
A 2020 study looking at patterns of gender convergence and divergence in US overdose deaths might shed light on the issue. Central to this study was the fact that the ratio of male-to-female UDIDs is not static but fluid. The total number of UDIDs has always been higher for men, but there have been times when the rate of increase in UDIDs was higher for women. These include the late 1800s and mid-1990s, two periods during which prescription opioids were much more freely prescribed, and in each case, the rate of increase was significant. In the late 1800s, when laudanum was widely used as a painkiller and sleeping aid, women actually surpassed men for incidence of drug dependence, if not mortality. This suggests that the gender gap is heavily influenced by external factors.
PEOPLE HAVEN’T REALLY FOCUSED ON HOW OVERDOSE VARIES ACROSS GENDERS, WHY IT VARIES ACROSS GENDERS, AND THE EXPERIENCES OF WOMEN AND TRANS AND GENDER DIVERSE FOLKS IN PARTICULAR.” “ “
Australia’s Annual Overdose Report 2022 found that men accounted for 71.3 per cent of unintentional drug-induced deaths (UDIDs) in 2020, and they reliably make up around two-thirds of UDIDs. The report also found that, while the incidence of UDIDs is increasing for both men and women, it is increasing more rapidly for men. Since 2012 the number of unintentional deaths among men increased by 45 per cent, while deaths among women increased by 12 per cent.
Healthcare data further complicates the picture. Australian hospital records from 2019-2020 reveal that most people who presented at emergency departments for drug-related poisoning were women, but those poisonings were less likely to result in death. This is partly explained by the types
The ratio of approximately two male deaths for every one female death is borne out with striking consistency around the world, with comparable figures observed in the US (70.2 per cent male), Canada (74), England and Wales (67.4), and Europe (79). This is not a recent development, nor is it news to those on the frontlines of drug-related issues. That men outnumber women for UDIDs is widely acknowledged, but perplexingly, it is rarely interrogated. Canadian psychologist and men’s mental-health specialist Dr. Dan Bilsker has spoken about his field’s apparent blind spot for gender. He has lamented that men’s disproportionately high mortality rates in suicide and overdose (the two closely mirror each other) are simply accepted, chalked up to an inherently male impulse towards self-destruction. Such a discrepancy, he argues, “needs explanation, it needs understanding, it needs response. It is not to be taken for granted.” Unfortunately, a straightforward explanation is not readily forthcoming. That more men die from unintentional overdose is clear, but beyond that the data are much less definitive, more varied, and often seemingly contradictory. Behind these numbers, we can begin to discern a more nuanced story about drugs and gender. The most popular theory is that men are more likely to engage in risk-taking behaviour, and high-risk drug use
leads to overdose deaths. Ask almost anyone what they think is behind the gender disparity in UDIDs and they are likely to give some version of this argument. While not flatly wrong, it is not as clear-cut as is often assumed, as risktaking behaviour is difficult to define and quantify. Even if we accept the answer as true, it only replaces our initial question with a new one: what drives men to take more risks? Is it an intrinsically, even genetically male characteristic, or are sociocultural factors to blame?
When the US opioid epidemic first struck over two decades ago, it confounded the widely held stereotype that heroin was only a problem for people of colour living in poor, urban communities. The phrase “addiction does not discriminate,” though not new, became a popular catchphrase and common coin within drug treatment and advocacy circles. It’s true that anyone can become dependent on drugs, but like so many headlines, this one lacks crucial context. There is ample evidence that problematic drug use affects some populations more than others, and in different ways. A notable example is the disparity between men and women in fatal overdose statistics.
likely to seek treatment for drug use, but women tend to have better outcomes when they do enter treatment; women are far more likely to experience sexual violence that compels them to self-medicate, but they are also better able to identify how their trauma influences their drug use, behaviours they are then able to address.
are
“We know that drug use is very much gendered, and we know that women and gender-diverse folks experience a lot of inequities that impact their drug use and that impact their overdose risk and their health outcomes. But it’s not a huge focus.
WOMEN USE MORE PHARMACEUTICAL DRUGS WOMEN HAVE BETTER SUPPORT NETWORKS WOMEN ARE MOTIVATED BY PREGNANCY & CHILD RAISING TO REDUCE DRUG USE WOMEN ARE MORE LIKELY TO COME INTO CONTACT WITH THE HEALTHCARE SECTOR WOMEN MAY AVOID ILLICIT DRUG-USE SETTINGS DUE TO RISK OF VIOLENCE MEN ENGAGE IN MORE RISK-TAKING BEHAVIOUR MEN USE MORE ILLICIT DRUGS MEN HAVE FEWER EMOTIONAL RESOURCES AND SUPPORT NETWORKS MEN ARE EXPERIENCING A CRISIS OF MASCULINITY VARIOUS EXPLANATIONS HAVE BEEN ADVANCED TO EXPLAIN THE GENDER DISPARITY IN UNINTENTIONAL OVERDOSE DEATHS. THESE INCLUDE:
There is no single cause for the gender disparity in UDIDs, but a web of probable contributing factors that interact in often surprising ways: studies show that men more
When gender and overdose do appear together in public discourse, these shadings are often absent, overshadowed by the less ambiguous male-to-female mortality rate. It is a dynamic familiar to US-based researcher Alexandra Collins. She doesn’t dispute the disparity in UDIDs or downplay its significance, but she cautions that women and genderdiverse people risk being sidelined if overdose is framed as a men’s health issue.
“People haven’t really focused on how overdose varies across genders, why it varies across genders, and the experiences of cis and trans women and gender-diverse folks in particular.”
Data that resist a satisfyingly straightforward interpretation may be one reason researchers have been slow to address
of substances consumed by each group: pharmaceutical opioids and illicit drugs were more prevalent in male drug poisonings, and women were more likely to overdose on non-opioid pharmaceutical drugs. A US study, meanwhile, found that women were more likely to be prescribed an opioid, were more likely to report using drugs to cope with emotional or physical pain, and progressed more quickly to substance use disorders following exposure to an addictive substance. There is strong evidence that women – as well as trans and nonbinary people – experience greater stigma relating to their drug use and encounter more barriers than men when attempting to access treatment. Given these compounding factors, we might wonder why the number of female UDIDs does not at least match that of men. In other settings, the differences are less pronounced. A spokesperson for the Melbourne Supervised Injecting Room in Richmond said there are only slight differences in overdose rates between men (2%) and women (1.5%) who attend the facility, and that gender was not a major consideration when delivering services.
“[I’m] not saying men aren’t impacted or men aren’t dying at greater rates,” she asserts, “it’s just that we can’t focus only on men, and we can’t just develop interventions that are
“It is all changing right now. In the US and Canada, we saw the highest rates of overdose deaths we’ve recorded. It’s hard to say who’s being impacted more because everyone’s being impacted.
supposed to be addressing overdose in a gender-neutral way, because more than just men use drugs.”
The data tells us that this issue is not gender-neutral, and yet most of our interventions proceed as if gender bears no Ifconsideration.wehopetoaccurately explain the source of the genderoverdose gap, we will need to acknowledge that our assumptions about causes – like male risk tolerance – are themselves loaded with gendered assumptions. Clearing away these preconceptions will help us move toward both an explanation of the gap and a conversation in which all identities and experiences are treated as valuable. the gender gap in UDIDs. Another may well be the polarising nature of gender issues. Focusing too heavily on male mortality carries risks; a high-impact statistic with no single cause, it has sometimes been co-opted by men’s rights groups eager to dismiss issues that disproportionately burden women, trans, and gender-diverse people.
For Alexandra, the lack of attention given to marginalised groups and the reticence to address gender in drug use are especially dangerous in the context of the ongoing COVID-19 pandemic and the explosion of synthetic psychoactive drugs like fentanyl.
Achieving a greater understanding of the drivers of the overdose-death gender gap remains a worthwhile goal. Whatever weight we attribute to the individual drivers, the fact remains that men are dying in disproportionately high numbers, and it would seem counterintuitive not to incorporate this knowledge into our interventions.
7 to to to1331to37 9 12 121213 14151835 WED TUESWED THURSTHURSTUES9:009:30WEDamam 12:00pm7:30pm 10:00 pm 10:00 Am SEPTOCTSEPT SEPTSEPTSEPTSEPTAUG SEPTSEPTOCTOCT APSAD APSAD Darwin 2022 Conference Insight Getting ripped or ripped off”Image and performance enhancing drugs in Queensland ATDC Tasmania Overdose Day Art Installation What’s new with naloxone? 3 lives a day saved with take home naloxone Caraniche Forensic Fundamentals (1/2 day) Training Insight Living the work. Exploring lived experience in the AOD workforce with Victoria Kostadinov ASHM IOAD 2022 Crane Folding Session Rethink Addiction National Conference Women’s Alcohol and Drug Service The impact on infants exposed to methamphetamine in pregnancy with Dr Anna Tottman 360Edge Trauma inside out: A two-day trauma masterclass HIV Nursing Webinar Risk DrugSubstanceManagement:Use-AndAlcoholIssues EventOnlineinfo: bit.ly/3P669rX Online & In Person, Hyatt Hotel, Canberra Event info: bit.ly/3ATWgcd Darwin Convention Centre Event info: bit.ly/3KppItv Novotel South Bank, EventBrisbaneinfo : bit.ly/3TmmyL5 EventOnlineinfo: bit.ly/3pMnkUe EventOnlineinfo: bit.ly/3axWSKd EventOnlineinfo: bit.ly/3AyKUsOEventOnlineinfo: bit.ly/3TiUEjf EventOnlineinfo: bit.ly/3CF9B9p EventOnlineinfo: bit.ly/3CCB1Nc Waterside Pavillion, Hobart Event info: bit.ly/3ThpTLv The Bulletin’s bimonthly event calendar features events from across Australia relevant to the NSP workforce. We would love to include your organisation’s event in the next edition. Please click here to submit the details for consideration. CALENDAR OF EVENTS SEPTEMBER + OCTOBER THE BULLETIN
